Question

A nurse is caring for a client who is in respiratory distress and requires endotracheal suctioning. Which of the following actions should the nurse take?

A. Use clean technique when suctioning the client's endotracheal tube.


B. Use a rotating motion when removing the suction catheter.


C. Suction the oropharyngeal cavity prior to suctioning the endotracheal tube.


D. Suction the client's endotracheal tube every 2 hr.

Answer 1

A nurse should assess the need for endotracheal suctioning based on the patient's condition, not just on a routine schedule. Monitoring for signs like secretions or changes in breathing, maintaining equipment readiness, following aseptic technique, and pre-oxygenating the patient are critical steps.

Step-by-step explanation:

When a client is in respiratory distress and requires endotracheal suctioning, it's important for a nurse to assess the need for suctioning based on the patient's condition rather than adhering to a strict schedule. Suctioning too frequently can cause trauma to the airway and potentially lead to other complications, while not suctioning often enough can impede the patient's breathing.

Instead of suctioning every 2 hours, the nurse should monitor the patient closely for signs that indicate a need for suctioning, such as secretions in the airway, a decline in oxygen saturation, or changes in breathing patterns. Before suctioning, the nurse should ensure that all necessary equipment is ready and functioning properly, and follow strict aseptic technique to prevent infection. It's also critical for the nurse to pre-oxygenate the patient to maintain adequate oxygenation levels.